Forms

Client Forms:

If you have signed up for a Nutrition “package” both the Client Contact Information and Client Pre-Assessment Forms must be submitted before your appointment is set up.

Client Contact Information:

Example: 07/18/1975
For appointments completed via Skype

Client Pre-Assessment Form:

Thank you for taking the time to complete the following information to the best of your ability.  This will be helpful to understand your history prior to your initial assessment, so your appointment time can be used to your benefit.

If you are unable to answer a question, type “unknown” in the appropriate space.  Once you are done and have filled in all the starred (*) questions, press ‘submit.’  Your work will NOT be submitted unless you receive a message saying that the submission was successful.

Please note: Prior to submitting your work, it is a good idea to copy and paste your answers onto a blank document to save your work.  That way if you run into problems submitting your work, you don’t need to panic!  Simply email the document with the saved information to Elisa@EatUrVeggies.com.  This could potentially save you a lot of time and frustration if there is a problem with the Internet server.

Inches

Pounds

Systolic mm Hg/Diastolic mm Hg

Blood sugar, Hemoglobin A1C, Insulin, Homocysteine levels, B12, Vitamin D, Calcium, Iron, etc...

Ex: Maternal grandmother - heart disease, diabetes; Paternal grandfather - cancer; Maternal Uncle - multiple sclerosis, etc...

Include your daily dose and the reason the medicine was prescribed.

Include daily amounts, reason for taking, and brand name.

If so, how many times each day, week, or month?

If yes, how many days per week? How long each day?

Ex: Lack of support, lack of time, lack of money, etc...

If so, please list them here.

Please list all food and drink consumed on a typical day. Include snacks, times, amounts, brand names and details as able.

Please list all food and drink consumed on a typical day. Include snacks, times, amounts, brand names and details as able.

Please list all food and drink consumed on a typical day. Include snacks, times, amounts, brand names and details as able.

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